Wellmark Bronze Primary Care | UnityPoint Health - 25896IA0370009 Health Insurance Plan

Wellmark Health Plan of Iowa, Inc. health insurance plan with the Plan ID 25896IA0370009. The plan is called Wellmark Bronze Primary Care | UnityPoint Health.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.16% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.84% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 25896IA0370009
Health Insurance Plan Year 2023
State Iowa
Health Insurance Issuer Wellmark Health Plan of Iowa, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 25896IA0370009-00
Provider Network(s) ['IAN002']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Iowa All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 25896IA0370009-00

Standard On Exchange Plan - 25896IA0370009-01

Open to Indians below 300% FPL - 25896IA0370009-02

Open to Indians above 300% FPL - 25896IA0370009-03

Last Plan Update Date Fri, 16 Sep 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan, 25896IA0370009-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental

Care must be completed within 12 months

YES

$110.00

100.00%
Acupuncture
NO
Allergy Testing

Allergy testing is a covered benefit

YES

$110.00

100.00%
Bariatric Surgery
YES

50.00% Coinsurance after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child

Pediatric dental not embedded

NO
Chemotherapy
YES

50.00% Coinsurance after deductible

100.00%
Chiropractic Care
YES

$25.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

50.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children

Pediatric dental not embedded

NO
Diabetes Education
YES

$25.00

100.00%
Dialysis
YES

50.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

50.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

80.00%

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

$35.00

100.00%
Habilitation Services
YES

50.00% Coinsurance after deductible

100.00%
Hearing Aids
NO
Home Health Care Services
YES

50.00% Coinsurance after deductible

100.00%
Hospice Services

Quantitative limits apply, see EHB benchmark.

YES

50.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

50.00% Coinsurance after deductible

100.00%
Infertility Treatment
YES

$25.00

100.00%
Infusion Therapy
YES

50.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

50.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

50.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child

Pediatric dental not embedded

NO
Mental/Behavioral Health Inpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$25.00

100.00%
Non-Preferred Brand Drugs
YES

50.00% Coinsurance after deductible

100.00%
Nutritional Counseling
NO
Orthodontia - Adult
NO
Orthodontia - Child

Pediatric dental not embedded

NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$25.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

50.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services
YES

50.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

50.00% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care
YES

50.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization

Quantitative limits apply, see EHB benchmark.

YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$25.00

100.00%
Private-Duty Nursing
YES

50.00% Coinsurance after deductible

100.00%
Prosthetic Devices

Prosthetic devices are covered

YES

20.00%

100.00%
Radiation
YES

50.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy
YES

$25.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

No limit on covered benefit

YES

50.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$110.00

100.00%
Specialty Drugs
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$25.00

100.00%
Transplant
YES

50.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

50.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$25.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care

Covered for child through age 7.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

50.00% Coinsurance after deductible

100.00%

Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan Variant 25896IA0370009-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.641616318
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID IAF001
Formulary URL URL
HIOS Product ID 25896IA037
Import Date 9/16/2022 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 25896
Issuer Marketplace Marketing Name Wellmark Health Plan of Iowa, Inc.
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID IAN002
Out of Country Coverage Yes
Out of Country Coverage Description Accidental injury and emergency services only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Accidental injury and emergency services only
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan ID (Standard Component ID with Variant) 25896IA0370009-00
Plan Marketing Name Wellmark Bronze Primary Care | UnityPoint Health
Plan Type HMO
Plan Variant Marketing Name Wellmark Bronze Primary Care | UnityPoint Health
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $300
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $7,800
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $700
SBC Scenario, Having Diabetes, Deductible $3,900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $500
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,900
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID IAS002
Source Name SERFF
Plan ID 25896IA0370009
State Code IA
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $15600 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7800 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,800
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $18000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design No
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan, 25896IA0370009

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Wellmark Bronze Primary Care | UnityPoint Health, 25896IA0370009 Health Insurance Plan, 25896IA0370009

  • Does Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan, 25896IA0370009 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (25896IA0370009) Health Insurance Plan, Variant (25896IA0370009-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (25896IA0370009) Health Insurance Plan, Variant (25896IA0370009-00) have Out Of Country Coverage?

    Yes. Details: Accidental injury and emergency services only

    Does (25896IA0370009) Health Insurance Plan, Variant (25896IA0370009-00) have Out of Service Area Coverage?

    Yes. Details: Accidental injury and emergency services only

    Does (25896IA0370009) Health Insurance Plan, Variant (25896IA0370009-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan, Variant (25896IA0370009-00) offer Disease Management Programs for Asthma?

    Yes, the Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan Variant 25896IA0370009-00 offers Disease Management Program for Asthma.

    Does Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan, Variant (25896IA0370009-00) offer Disease Management Programs for Heart disease?

    Yes, the Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan Variant 25896IA0370009-00 offers Disease Management Program for Heart disease.

    Does Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan, Variant (25896IA0370009-00) offer Disease Management Programs for Depression?

    Yes, the Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan Variant 25896IA0370009-00 offers Disease Management Program for Depression.

    Does Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan, Variant (25896IA0370009-00) offer Disease Management Programs for Diabetes?

    Yes, the Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan Variant 25896IA0370009-00 offers Disease Management Program for Diabetes.

    Does Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan, Variant (25896IA0370009-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan Variant 25896IA0370009-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan, Variant (25896IA0370009-00) offer Disease Management Programs for Low back pain?

    Yes, the Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan Variant 25896IA0370009-00 offers Disease Management Program for Low back pain.

    Does Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan, Variant (25896IA0370009-00) offer Disease Management Programs for Pregnancy?

    Yes, the Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan Variant 25896IA0370009-00 offers Disease Management Program for Pregnancy.

    Does Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan, Variant (25896IA0370009-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Wellmark Bronze Primary Care | UnityPoint Health Health Insurance Plan Variant 25896IA0370009-00 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API